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The Nursing Shortage

Joanne Rosenberg has been a registered nurse at North Shore Hospital in Forest Hills, Queens, for almost 30 years. Her job has always been difficult, but today as she scrambles to tend to more patients, she worries that she is unable to provide the care she would like to give. "Every patient deserves full attention, but it's not realistic," she said. "Sometimes you have to do shortcutsâ€¦ You don't want to do that, but there's only so much the body can do."

New York has a nursing shortage. Last April, 59 city hospitals reported a total of 2,000 vacancies, or nearly 8 percent of their nursing workforce. By 2005, New York State estimates it will have 17,000 fewer nurses than it needs, and that number could double by 2015.

"We are edging closer to a precarious situation," said Kenneth E. Raske, president of the Greater New York Hospital Association. "We must make sure that we have enough nurses to care for future generations." The shortage comes at a time when the demand for nurses is increasing as the baby boom generation ages and requires more medical care. And unlike some of the previous shortages, it could last for many years, if not decades, to come. Fewer young people are choosing careers in nursing, and many nurses are nearing retirement age themselves or just quitting from stress and overwork. Proposed cuts in government spending for health care threaten to make the situation worse.

The shortage in the city is not only taking its toll on nurses and hospitals, but on patient care -- lines at emergency rooms are longer, surgeries are delayed, and even the risk of dying in a hospital may be increasing.

"There is absolutely no question that you cannot have quality care without nurses," said Georgia Persky, vice president of Mount Sinai Hospital in Queens. "Patients need someone constantly, critically looking at them in a unique way that only a nurse can provide."

THE EFFECT ON CARE

Nurses generally provide about 80 percent of direct patient care in hospitals. They assess the patient's condition, administer medications and maintain medical records. They look out for symptoms and report them to physicians.

"Nurses are the eyes and ears in a hospital," said Nancy Webber of the New York State Nurses Association. "If they have too many patients to care for they simply can't do that to the extent they should and want to."

Nurses' workloads vary widely. But more than 25 percent of nurses in the state say they do not have time to complete all the tasks involved in caring for patients, and 45 percent say they do not have time to provide a thorough assessment of their patients, according to a 1999 survey conducted by the New York State Nurses Association.

This can put patients' lives in jeopardy. Whenever a patient is added to a nurse's workload, the chance that one of that nurse's patients will die within 30 days of admission increases by 7 percent, researchers at the University of Pennsylvania found.

Some of this results from the strain of an excessive workload. "If you don't get enough rest you may give the wrong medications to the patient. And that's scary," said Pui Ching Mak, who worked at Bellevue Hospital and is now a nursing manager at Visiting Nurse Service of New York. "I had this nurse one time who gave a chemo medication to another patient."

The nursing shortage also forces people to wait for care. "Sometimes we [have] had to reschedule an operation because there was not enough staff," said Freddy Haro, who worked as a medical technician at Memorial Sloan-Kettering Cancer Center for 12 years and recently got his nursing degree.

In nursing homes, where vacancy rates are 10 percent, the shortage of nurses and of nursing assistants, who take care of residents' personal needs, has a particularly dramatic effect.

"Residents in nursing homes often do not have their diapers changed appropriately, or they are not assisted in toilet training, call bells are not responded to promptly, because there is not enough staff," said Randy Blom, a counselor at Friends and Relatives of Institutionalized Aged, an advocacy group.

A DIFFICULT JOB

Nursing has traditionally been a women's profession, but as job opportunities for women have expanded, fewer have chosen nursing careers. According to a survey by the American Association of Colleges of Nursing, over the last five years, the number of graduates from nursing programs declined by an average of 1,030 students each year.

Many are deterred because nursing can be dirty, intense, demanding work -- far different from a job in an office. "When you are a nurse you need to handle dirty stuff - urine, sputum, body fluids. Not everybody wants to do that," said Mak.

Many people do not want to deal with the tension that's prevalent in healthcare facilities." In nursing, there is not much room for you to make a mistake, and when you do make a mistake you pay for it severely," said Vetah Okuomose, a registered nurse who works in a school in Queens. "It's a rewarding profession, but it's a very serious profession."

Caring for a terminally ill patient or seeing a person die is not something everybody can handle. Susan Hertz, a recent graduate of the nursing program at Kingsborough Community College, said, "It's a challenge when someone is in great pain and you can't take that away from them," she said. "We are in a role where we want to make a difference, but if we can't make a difference for somebody, that's tough."

Nurses also complain they do not get the respect they deserve.

"Nurses are often treated horribly by doctors," said Naomi Zauderer, director of New York Professional Nurses Union. "It helps if they are unionized, but without some serious changes in workplace conditions the profession will continue to hemorrhage nurses."

And the pressures are increasing because of managed care. Because patients do not stay in hospitals as long as they once did, those who are left there are there are usually sicker and require more nursing than patients 20 years ago.

Faced with such challenges, many nurses leave the profession. The U.S. Department of Health and Human Services found 19 percent or about 240,000 registered nurses in New York State are not employed, by their own choice. Over the past four years about 8,000 nurses in New York have quit their jobs.

Perhaps the most alarming factor affecting the shortage is that the average retirement age for nurses in New York State is 49, and the average age of a registered nurse in New York is 46.

"In the next five or ten years we all are going to retire," said Diane Mapp, a registered nurse at Long Island College Hospital in Brooklyn, who has been a nurse for 28 years. "I can't see myself at 60 doing this anymore."

RECRUITMENT EFFORTS

Healthcare providers and educators are struggling to come up with strategies to recruit more nurses.

Hospitals in New York generally offer nursing graduates salaries ranging from $48,000 to $55,000. Some provide tuition reimbursement or scholarships. New York Presbyterian Hospital, for example, offers $10,000 in tuition benefits at Columbia Medial Center to nurses who want advanced training. New York University Hospital gives monetary remuneration for nurses who receive certification in specialty areas.

"It's absolutely critical to make nursing a very appealing job, which starts at a threshold level with paying a competitive salary, but [also improving] the job design and the working conditions," said Denise Davin, vice president for Human Resources at Visiting Nurse Service of New York, which employs over 2,000 nurses.

Training programs are also being expanded.

City University of New York has not been able to accommodate all the applicants to its nursing programs because there are not enough professors. Borough of Manhattan Community College, which has the largest nursing program of all CUNY schools, had to turn down 70 applicants to the nursing program in 2001, the New York Times reported. To address this, CUNY is adding 30 instructors to its nursing programs.

"It's expensive, but we have an obligation to provide work-force training where there is such a great need," CUNY Chancellor Matthew Goldstein has said.

Last year, CUNY created a special program for immigrant nurses with poor language skills who want to get licensed in New York. The 18-month program helps them master English and prepares them to pass the licensing examination. Currently 40 immigrant nurses are enrolled in the program.

The state and federal governments have also taken steps to address the problem.

In January, 2002, Governor George Pataki signed the Health Care Workforce Recruitment and Retention Act, which granted $1.85 billion to hospitals, nursing homes, and other health care facilities. The money would help the facilities recruit and retain workers and increase salaries and would encourage employees to advance in their profession. The current state budget crunch could, however, undermine parts of this program.

The Nurse Reinvestment Act, signed by President Bush last summer, authorized more loans and scholarships to nursing students and offered grants to healthcare providers to help them recruit and keep nurses. The Senate has approved $20 million in new federal funds for the act for the fiscal year 2003.

Training programs, hospitals and colleges are reaching out to the younger generation, trying to encourage them to become nurses. Borough of Manhattan Community College allows high school students to take college credit pre-nursing courses. Kingsborough Community College has been working with several high schools in Brooklyn to raise awareness of the importance of health careers and the need for more people to enter them. "We really need to go into the schools at a very young age, get to the younger population and sort of market nursing, not just for women, but also for men," said Willie Manzano, vice president for Patient Care Services at Columbia Presbyterian Medical Center. Fewer than 6 percent of nurses in New York are men.

Visiting Nurse Service of New York, which faces a 10 percent vacancy rate, is going to the army and the Fire Department to recruit potential nurses. It currently employs five firefighters. Patrick Murpagh, a visiting nurse who is also currently a firefighter, believes this is a good time to try to bring these workers into nursing.

"Both [nursing and firefighting] are service orientated occupations," he said. "After 9/11 there have been a lot of retirements, so I think that [firefighters] will be looking to going into different careers and nursing would be a perfect opportunity for a lot of them."

In the 1980s, many hospitals relied on nurses from abroad to alleviate the problem. But, while some still do this, the tactic is less effective than it once was because many other countries also face a nursing shortage.

RETENTION INCENTIVES

To retain nurses, health care providers and lawmakers try to make the job as attractive as possible. That often entails offering flexible hours and bonuses, lowering the nurse-patient ratio and not requiring overtime. Many hospitals offer 12-hour shifts, which some nurses prefer to shorter, more frequent workdays.

New York State Assemblywoman Catherine Nolan and Senator Thomas Morahan have proposed a bill that would prohibit hospitals from requiring a nurse to work more than eight hours a day or 40 hours a week, unless her regular schedule allows for more. The requirement could be suspended during "health care disasters" and publicly declared emergencies.

Hospital management however, argues that some overtime is unavoidable when there is a sudden surge in patients or nurses call out sick. "When we have sick calls, and we can't cover the sick calls with either a per diem nurse or an agency nurse, then we end up asking people to stay. Sometimes they don't do it happily, but we work it out," said Manzano.

Assemblymember Richard Gottfried and State Senator Kemp Hannon have introduced a bill that would require the State Department of Health to establish universal staffing standards for health care facilities, based on the severity of the patient's condition.

Another bill, also introduced by Gottfried, would apply only to nursing homes. It would ensure that in every nursing home during the day shift there are no more than 15 residents for every registered nurse. Many nursing home nurses care for 30 or more residents.

While overworked nurses support the legislation, some health care organizations claim that a universal nurse-patient ratio would only worsen the current situation. "You can't offer some formula and say x number of nurses for x number of patients for this floor," said Monica Mahaffey of the Healthcare Association of the New York State. "The healthcare providers know the . . .needs of the patients, and they should be the ones ensuring that those patients are getting the best care they can." Health care organizations have been lobbying for decreasing the amount of paperwork for nurses. The law requires that nurses maintain records on the evaluation and treatment of each patient. Some nurses at Bellevue Hospital stay an hour and a half extra every day to complete the required records.

"For every hour of patient care, nurses do at least another hour of paperwork," said Mahaffey. "Let's find a way to get them back to the bedside. Let's use the nurses we have to provide direct care and find some other way to take care of these paperwork requirements."

THE FUTURE OF NURSING IN NEW YORK

New York will not be able to alleviate the shortage of nurses unless ideas and incentives are backed up by money. And money is in short supply these days.

On January 29, Governor Pataki released a proposed budget imposing more than $1 billion in cuts that would have a great impact on health care providers, their staff and patients.

"When you take a billion dollars out and 60 percent of the cost of a hospital is labor, you run the risk of jeopardizing the workforce supply," Daniel Sisto, president of Healthcare Association of New York State, said on Capital News 9.

The governor also proposed reinstating a tax on hospital revenue. According to the New York Times, that will cost hospitals more than $228 million a year and "could, along with cuts to Medicaid reimbursements of another $317 million, lead to layoffs of hospital workers."

It is unclear whether the governor's proposals will be enacted. But such ideas, along with the $343 million in operating losses that New York health providers experienced in 2001, cuts in federal Medicare funds, and rising costs, do not bode well for the nursing situation.

"The nursing shortage is a scary problem," said Persky. "I would not venture to guess what the future is. It will only be what effort we put into it."

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